Competency-Based Education: A Review of Policies and Implications for Respiratory Care Accreditation

Transcription

1 Competency-Based Education: A Review of Policies and Implications for Respiratory Care Accreditation Commission on Accreditation for Respiratory Care May 18 th, CoARC Report on Competency-Based Education 1

2 2012 All rights reserved. Commission on Accreditation for Respiratory Care, Inc Harwood Road Bedford, TX CoARC Report on Competency-Based Education 2

3 Introduction... 4 What is Competency-Based Education?... 5 Why Competency-Based Education?... 6 Competency-Based Education in the Health Professions Competency-Based Education in Respiratory Care A Renewed Emphasis on Inter-Professional Competencies The Differentiated Practice Model and Its Role in CBE Suggested Evidence for Measuring the Success of a CBE Approach Concluding Remarks Resources and Suggesting Reading Board of Commissioners and Executive Office Staff Listing CoARC Report on Competency-Based Education 3

4 INTRODUCTION As CoARC undergoes the process of revising its existing accreditation standards as well as begins the process of developing graduate level accreditation standards for an advanced practice respiratory therapist, it is important for the CoARC Board to consider the policy approaches covered in this report. Such approaches align with CoARC s continued emphasis on the importance of student learning outcomes that focus on the competencies and attainment levels reached by students upon completion of their program. The purpose of this report is to inform the CoARC Board and other key stakeholders in the respiratory care profession of the implications of competency-based education as it relates to the accreditation process. First, a description of the key characteristics of competency-based education will be provided. How competency-based education has become the recent focus of many health profession organizations will then be reviewed. Approaches by other specialized and professional health professions accreditors will also be reviewed. This will be followed by a review of the approaches to competencybased education for the respiratory care profession. A discussion of inter-professional competencies and its increasingly important role is summarized. The role that a differentiated practice model plays in a competency-based approach is also provided. The report concludes with some suggested evidence for evaluating a successful competency-based approach as well as some final comments to stimulate future dialogue on this topic. CoARC Report on Competency-Based Education 4

5 WHAT IS COMPETENCY-BASED EDUCATION? In a seminal article, Epstein and Hundert established a commonly cited definition of competency in the health care professions as the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served (Epstein & Hundert, 2002, p. 226). Although there are many contextual variations when defining the term, a competency is generally viewed as encompassing the full array of knowledge, skills, attitudes, and other characteristics (KSAOs) for completing a task or course of study or performing a job, rather than simply knowledge alone (Calhoun, Wrobel, & Finnegan, 2011, p. 152). Competency-based education refers to educational programs designed to ensure that students achieve pre-specified levels of competence in a given field or training activity. A core competency is the identified knowledge, ability, or expertise in a specific subject area or skill set that is shared across the health professions (Institute of Medicine, 2003, p. 24). The term competency has also been used to refer to actual performance in a specific job duty or task, and competencies or competency areas are skills considered necessary to perform a specific job or service (Kelly- Thomas, 1998). Gradations in the level of competence have also been CBE addresses what graduates are expected to do (e.g., solve problems, communicate effectively, and provide appropriate care) upon completion of their program of study rather than on what they are expected to learn about during the course of their study. - Richards & Rogers 2001 described in the literature. Hubert and Stuart Dreyfus describe a model for skill acquisition that occurs in five stages along a continuum of learning. These stages include (1) novice; (2) advanced beginner; (3) competence; (4) proficiency; (5) expert (Dreyfus & Dreyfus, 1986). At the level of competence, a student can think conceptually and execute planned approaches to care based on the standards and rules they have learned (Gunderman, 2009, pp ). The term student learning outcomes is often used synonymously with competencies. The Council for Higher Education Accreditation (CHEA) defines student learning outcomes in terms of the knowledge, skills, and abilities that a student has attained at the end (or as a result) of his or her engagement in a particular set of higher education experiences (CHEA, 2006, p. 1). In the 2001, the Council for Higher Education Accreditation (CHEA) published a policy document, Accreditation and Student Learning Outcomes: A Proposed Point of Departure, which provided accrediting organizations with a conceptual framework and taxonomy for integrating student learning outcomes into the accreditation review process. In the document, Peter Ewell of the National Center for Higher Education Management Systems states that the student learning outcome approach requires institutions or programs to define learning goals from the outset as guides for instruction and for judging individual student attainment. Expressed in terms of competencies, moreover, such goals describe not only what is to be learned but also the specific levels of performance that students are expected to master (Ewell, 2001, p. 6). The document also defines certification to mean that the expected competencies have actually been attained. Bear in mind that not all outcomes in higher education are related to student learning. For instance, job placement rates, career mobility, retention, CoARC Report on Competency-Based Education 5

6 higher income levels, etc. are examples of outcomes that are indirectly related to the learning process and educational experience. These metrics are more appropriate descriptors for evaluating institutional effectiveness rather than student learning and achievement. Similarly, student, graduate, and employer satisfaction surveys are important indicators of overall program effectiveness, but should not be confused with student learning (CHEA, 2006, p. 5). The central focus of competency based education (CBE) is on student learning outcomes. In the context of accreditation, CBE addresses what graduates are expected to do (e.g., solve problems, communicate effectively, and provide appropriate care) upon completion of their program of study rather than on what they are expected to learn about during the course of their study. CBE is certainly not a new approach to education it has been in existence for almost four decades- only in the past decade has it gained widespread acceptance in the higher education community. In a CBE framework, educational goals are defined in terms of precise measurable descriptions of knowledge, skills, and behaviors students should possess at the end of a course of study (Richards & Rogers, 2001). From the perspective of health professions education, CBE is a framework that focuses on the desired performance characteristics of health care professionals. CBE makes explicit what has been an implicit goal of traditional educational frameworks, by instituting observable and measureable outcomes that students are expected to achieve. The ability to perform to established expectations is the criteria by which a health professional is deemed competent. By placing emphasis on results rather than processes, CBE provides a substantial shift in what accreditors and other stakeholders look for in judging the effectiveness of educational programs (Gruppen, Mangrulkar, & Colars, 2010). Traditionally, accreditation standards included a set of recommended or mandated courses of instruction that are based on the traditions, priorities, and values of the particular profession. Over time, the curriculum is slowly modified to accommodate new content in an attempt to keep pace with the rapidly changing, technology-driven health care environment. Competency-based accreditation standards focus on the requisite competencies needed for entry into a profession, allow flexibility in the curriculum to achieve competencies, and establish criteria to assess achievements and deficiencies by monitoring outcomes. By focusing on the outcomes of education, the approach is more transparent and therefore accountable to students, policymakers, and the public (Frenk, Chen, & et al., 2010). CBE s emphasis on student performance as evidence for having achieved a competency is predicated on the ability to accurately and validly measure performance in tasks and situations reflective of that competency (Gruppen, Mangrulkar, & Colars, 2010). WHY COMPETENCY-BASED EDUCATION? A review of the policies of various stakeholders in higher education reveals an increasing shift from a traditional, curriculum-centric approach of defining required courses to an outcomes-centric approach that establishes requisite competencies as the primary means to assess the achievement of expected student learning outcomes. The movement to competency-based education began in the 1970s and has since gained considerable momentum, particularly in the past decade due largely to growing concerns CoARC Report on Competency-Based Education 6

7 about patient safety (Institute of Medicince, 2001). Furthermore, educators recognized the value of using the competency approach to guide educational program design to develop specific learning objectives for each competency (AAMC-HHMI Committee, 2009). In today s knowledge economy, it is not sufficient for a graduate to demonstrate adequate basic cognitive skills and professional competencies. The nature of the health care field also requires that the graduate be able to work in teams, be a creative problem solver, and communicate with a diverse set of colleagues and patients. Employers and higher education institutions have become more cognizant of the role that such so-called soft or non-cognitive skills play in the successful performance in both academic and nonacademic arenas (Swyer, Millett, & Payne, 2006, p. 14). Calls by the public and policymakers for increased transparency and accountability as well as heightened consumerism have also influenced the shift to a competencycentered, outcomes-based approach to accreditation and the emphasis for accreditors to focus their standards on assessing the degree to which the professions are creating a skilled, competent, and globally competitive workforce. In December 1998, the Pew Commission on the Health Professions published the report, Recreating Health Professional Practice for a New Century, that outlines a number of recommendations aimed at transforming the health professions workforce (O' Neil & Pew Health Professions Commission, 1998). Among the recommendations was a call for health professions programs to realign training and education to be more consistent with the changing needs of the care delivery system. The four action steps for fulfilling this recommendation were: 1. Professional school faculties and administration should evaluate their current course of study to determine whether or not they are adequately preparing students to meet the challenges set forth in the competencies; 2. Professional associations should integrate the Calls by the public and policymakers for increased transparency and accountability as well as heightened consumerism have also influenced the shift to a competency-centered, outcomesbased approach to accreditation and the emphasis for accreditors to focus their standards on assessing the degree to which the professions are creating a skilled, competent, and globally competitive workforce. - Recreating Health Professional Practice for a New Century competencies into their accreditation and licensing processes, benchmarks for graduation, entry into professional practice and continuing competence; 3. Students should assess the quality of educational programs based on how well they will prepare them to apply the competencies in their careers; 4. Hospitals and other institutional providers should prefer partnerships with academic institutions that continuously revise their curricula to reflect changing market dynamics and that embody the competencies (O' Neil & Pew Health Professions Commission, 1998, p. iii). To assist in this process, the Pew Commission revised its 1993 competencies and identified twenty-one CoARC Report on Competency-Based Education 7

8 ; COMMISSION ON ACCREDITATION competencies for a changing health care system: 1. Embrace a personal ethic of social responsibility and service; 2. Exhibit ethical behavior in all professional activities; 3. Provide evidence-based, clinically competent care; 4. Incorporate the multiple determinants of health in clinical care; 5. Apply knowledge of the new sciences; 6. Demonstrate critical thinking, reflection, and problemsolving skills; 7. Understand the role of primary care; 8. Rigorously practice preventive health care; 9. Integrate population-based care and services into practice; 10. Improve access to health care for those with unmet health needs; 11. Practice relationship-centered care with individuals and families; 12. Provide culturally sensitive care to a diverse society; 13. Partner with communities in health care decisions; 14. Use communication and information technology effectively and appropriately; 15. Work in interdisciplinary teams; 16. Ensure care that balances individual, professional, system and societal needs; 17. Practice leadership; The Pew Commission report also cited the changing health care delivery system as a contributing factor for the increased demand for allied health professionals who offer a wider range of clinical skills, better preparation in management, greater experience in independent practice, and more flexibility in adapting to various practice settings. The report also identifies the increased demand by employers for practitioners who are culturally sensitive, teamfocused, and possess interpersonal and listening skills. - O' Neil & Pew Health Professions Commission, 1998, p Take responsibility for quality of care and health outcomes at all levels; 19. Contribute to continuous improvement of the health care system; 20. Advocate for public policy that promotes and protects the health of the public; 21. Continue to learn and help others learn (O' Neil & Pew Health Professions Commission, 1998, pp ). Interestingly, the Pew Commission report also cited the changing health care delivery system as a contributing factor for the increased demand for allied health professionals who offer a wider range of clinical skills, better preparation in management, greater experience in independent practice, and more flexibility in adapting to various practice settings. The report also identifies the increased demand by employers for practitioners who are culturally sensitive, team-focused, and possess interpersonal and listening skills (O' Neil & Pew Health Professions Commission, 1998, p. 47). CoARC Report on Competency-Based Education 8

9 Shortly after the Pew Commission report was released, the Institute of Medicine (IOM) published a report, Crossing the Quality Chasm: A New Health System for the 21 st Century, that recommended an interdisciplinary summit be held to develop next steps for reform of All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidencebased practice, quality improvement approaches, and informatics. - Institute of Medicine, 2003, p. 3 health professions education in order to enhance patient care quality and safety (Institute of Medicince, 2001). In June 2002, the IOM convened this summit, which included 150 participants across disciplines and occupations. In 2003, the US Institute of Medicine (IOM) called upon higher education institutions to not only increase the number of health professions graduates, but also to elevate graduates knowledge, skills, and abilities needed for meeting the ever-changing health care field. In what has become a seminal document facilitating the movement to a competency-based approach to education and accreditation, the IOM detailed five core competencies needed across the health professions, expressed through a vision to be shared by all institutions of health professions education: All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics (Institute of Medicine, 2003, p. 3). The five core competencies are described as follows: 1. Provide patient-centered care. Identify, respect, and care about patients. differences, values, preferences, and expressed needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health; 2. Work in interdisciplinary teams. Cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable; 3. Employ evidence-based practice. Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible; 4. Apply quality improvement. Identify errors and hazards in care; understand and implement basic safety design principles, such as standardization and simplification; continually understand and measure quality of care in terms of structure, process, and outcomes in relation to patient and community needs; and design and test interventions to change processes and systems of care, with the objective of improving quality; 5. Utilize informatics. Communicate, manage knowledge, mitigate error, and support decision making using information technology (Institute of Medicine, 2003, pp ). CoARC Report on Competency-Based Education 9

10 The IOM also encouraged educational accrediting agencies to expand from an assessment model focused on structure and process to one that includes evaluation of the institutions based on student-centered outcomes (Calhoun, Wrobel, & Finnegan, 2011, p. 15). Specifically, Recommendation #3 called on accreditors to: move forward expeditiously to revise their standards so that programs are required to demonstrate through process and outcome measures that they educate students in both academic and continuing education programs in how to deliver patient care using a core set of competencies. In so doing, these bodies should coordinate their efforts (Institute of Medicine, 2003, p. 8). In response to the increasing role learning outcomes play in accreditation, CHEA, the non-governmental higher education organization that recognizes 60 institutional and programmatic accrediting organizations, published a set of statements to provide a common platform upon which to develop appropriate policies and review processes that use evidence of student learning to improve practice, to improve communication with important constituents, and to inform judgments about quality (CHEA, 2003, p. 1). The three key recommendations for accreditors outlined in the report are: Recommendation #3 called on accreditors to: move forward expeditiously to revise their standards so that programs are required to demonstrate through process and outcome measures that they educate students in both academic and continuing education programs in how to deliver patient care using a core set of competencies. In so doing, these bodies should coordinate their efforts. - Institute of Medicine, 2003, p Accrediting organizations are responsible for establishing clear expectations that institutions and programs will routinely define, collect, interpret, and use evidence of student learning outcomes. More specifically, accreditors should establish standards and review processes that visibly and clearly expect accredited institutions and programs to: a. Regularly gather and report concrete evidence about what students know and can do as a result of their respective courses of study, framed in terms of established learning outcomes and supplied at an appropriate level of aggregation (e.g., at the institutional or program level); b. Supplement this evidence with information about other dimensions of effective institutional or program performance with respect to student outcomes (e.g., graduation, retention, transfer, job placement, or admission to graduate school) that do not constitute direct evidence of student learning; c. Prominently feature relevant evidence of student learning outcomes along with other dimensions of effective institutional performance, as appropriate in demonstrating institutional or program effectiveness (CHEA, 2003, p. 1). 2. Accrediting organizations are responsible for using evidence of student learning outcomes in making judgments about academic quality and accredited status. Establish and apply standards, policies, and review processes that examine how institutions and CoARC Report on Competency-Based Education 10

11 programs develop and use evidence of student learning outcomes for internal quality assurance and program improvement. Working with an institution or program, examine: o whether expectations of student learning outcomes are set at an appropriate level for the mission, student population, and resources of the institution or program; o whether the actual achievement levels of students against these standards are acceptable given the mission, student population and resources of an institution or program, and, in the case of the professions, the professional community served; and o whether the institution or program makes effective use of evidence of student learning outcomes to assure and improve quality. Ensure that using evidence of student learning outcomes plays a central role in determining the accredited status of an institution or program. Accrediting organizations are responsible for using evidence of student learning outcomes in making judgments about academic quality and accredited status. Establish and apply standards, policies, and review processes that examine how institutions and programs develop and use evidence of student learning outcomes for internal quality assurance and program improvement. - CHEA 2003, p Accrediting organizations should: o establish standards, polices, and review processes that visibly and clearly expect institutions and programs to discharge the above responsibilities with respect to public communication about student learning outcomes, o clearly communicate to accreditation s constituents the fact that accredited status signifies that student achievement levels are appropriate and acceptable, and o provide information about specific proficiencies or deficiencies in aggregate student academic performance, if these played a role in an accreditation action or decision about an institution or program (CHEA, 2003, p. 2) With shortages in the health care workforce projected over the next couple of decades coupled with increasing demands by employers for graduates to possess a skillset needed to successfully deal with the health care needs of the 21st century, the Department of Education (DOE), under the leadership of Secretary Margaret Spellings, responded in 2006 with further recommendations for transforming the US higher education system that included, among others, that higher education institutions should measure and report meaningful student learning outcomes. Recommendation #3 of the report describes the changes to be instituted by accrediting organizations: CoARC Report on Competency-Based Education 11

12 Accreditation agencies should make performance outcomes, including completion rates and student learning, the core of their assessment as a priority over inputs or processes. A framework that aligns and expands existing accreditation standards should be established to (i) allow comparisons among institutions regarding learning outcomes and other performance measures, (ii) encourage innovation and continuous improvement, and (iii) require institutions and programs to move toward world-class quality relative to specific missions and report measurable progress in relationship to their national and international peers. In addition, this framework should require that the accreditation process be more open and accessible by making the findings of final reviews easily accessible to the public and increasing public and private sector representation in the governance of accrediting organizations and on review teams. Accreditation, once primarily a private relationship between an agency and an institution, now has such important public policy implications that accreditors must continue and speed up their efforts toward transparency as this affects public ends (US Department of Education, 2006, p. 25). In late 2006, a DOE accreditation forum was held to introduce the resulting recommendations to key stakeholders and to explore implementation strategies. The onus for implementing these recommendations was placed on the accrediting organizations (Calhoun, Wrobel, & Finnegan, 2011). COMPETENCY-BASED EDUCATION IN THE HEALTH PROFESSIONS Accreditation agencies should make performance outcomes, including completion rates and student learning, the core of their assessment as a priority over inputs or processes. - Department of Education, 2006, p. 25 Many US accrediting agencies have responded to the recommendations from the Pew Commission, IOM, CHEA, and DOE by enacting significant changes to their accreditation standards and review processes. While almost all of the eight regional accrediting agencies have recently modified their standards and evaluation processes to increase the emphasis on student learning outcomes (Ewell, 2001), the past five years have also seen acceleration in the development of competencies and review processes for specialized and professional accreditors- particularly in the health professions. Many of these efforts have been driven by the professional organizations themselves, in an attempt to define expected knowledge, skills and behaviors of graduates entering practice (Gruppen, Mangrulkar, & Colars, 2010). The accrediting organizations for dentistry, health care management, medicine, nursing, pharmacy, physician assistant, athletic training, health information management, occupational therapy, physical therapy, dietetics, acupuncture and oriental medicine, nuclear medicine technology, and public health currently all require that core and/or specific competencies be achieved as stated in their respective accreditation documents, or alternately require individual programs to develop, implement, and document their own individualized competencies. CoARC Report on Competency-Based Education 12

13 The past five years have also seen acceleration in the development of competencies and review processes for specialized and professional accreditors- particularly in the health professions. Many of these efforts have been driven by the professional organizations themselves, in an attempt to define expected knowledge, skills and behaviors of graduates entering practice. - Gruppen, Mangrulkar, & Colars, 2010 It is should be mentioned that shifting the accreditation review process from a traditional model to a competency-based model does have its challenges. Lack of faculty familiarity with CBE learning and assessment methods appears to be the primary constraint to successful implementation (Calhoun, Wrobel, & Finnegan, 2011). The time required for restructuring course curricula to include essential team-based and integrative learning methods, competing priorities, and overall resistance to change can also impede implementation. Other challenges to the establishment of a successful CBE include failure to appropriately address community health needs, competencies that are inadequately defined or too broad, and deficiencies or absence of assessment methods to determine when competencies have been achieved (Gruppen, Mangrulkar, & Colars, 2010). The remaining section of this report provides a summary of the approaches to competency-based education by the various health professions and their respective accrediting agencies. Medicine In 1996, the American Association of Medical College s (AAMC) Medical School Objectives Project (MSOP) was established to help medical schools determine the outcomes of the medical student education program. The MSOP project and other competencies explicitly recognize the need to change and adapt competencies to meet changing educational, science, and health care developments (AAMC-HHMI Committee, 2009, p. 37). The MSOP developed basic and clinical science competencies for admission into and graduation from medical school. The first eight competencies focused on the sciences basic to medicine that students must gain by the completion of medical school. In what follows, the committee first presents those competencies deemed important for medical school education, followed by those identified for entering medical students. The competencies and their corresponding learning objectives are accompanied by examples of a few ways the competency could be included in an educational program (AAMC-HHMI Committee, 2009, p. 7). The Accreditation Council for Graduate Medical Education (ACGME) began its general competency and outcome initiative in This initiative, called the Outcome Project, requires that US graduate medical education programs foster resident physicians development of competencies in six domains and collect performance data that reliably and accurately depicts residents ability to care for patients and to work effectively in healthcare delivery systems. This approach assumes that quality patient care results CoARC Report on Competency-Based Education 13

14 when residents acquire and apply competencies effectively (Swing, 2007, p. 648). The ACGME and American Board of Medical Specialties (ABMS) jointly identified six domains of general competencies (and 24 competencies). Beginning in 2001, medical residents, and subsequently in 2008, one-year fellows, are evaluated on these six core competency domains (competency statements for one-year fellows are provided in bulleted format): Nursing (1) Patient care (compassionate, appropriate, effective) Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health; (2) Medical knowledge (biomedical, clinical, cognate sciences, and their application) Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care; (3) Practice-based learning and improvement (investigation and evaluation, appraisal and assimilation of evidence) Develop skills and habits to be able to meet the following goals: o systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement, and o locate, appraise, and assimilate evidence from scientific studies related to their patients health problems; (4) Interpersonal and communication skills (effective information exchange, teaming with patients and families) Demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals; (5) Professionalism (carrying out professional responsibilities, ethics, sensitivity) Demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles; and (6) Systems-based practice (awareness and responsiveness to larger context and system of health care, use of system resources) Demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care (Accreditation Council for Graduate Medical Education, 2012, pp. 4-5) The American Association of Colleges of Nursing (AACN) publishes curricular and competency requirements (i.e., Essentials) for the baccalaureate, master s, and doctoral programs in nursing. The 2011 Essentials of Master s Education in Nursing emphasizes that the master s-prepared nurse will be able to: CoARC Report on Competency-Based Education 14

15 1. Lead change for quality care outcomes; 2. Advance a culture of excellence through lifelong learning; 3. Build and lead collaborative inter-professional care teams; 4. Navigate and integrate care services across the healthcare system; 5. Design innovative nursing practices; and 6. Translate evidence into practice. Master s degree nursing programs prepare graduates with enhanced nursing knowledge and skills to address the evolving needs of the healthcare system (American Association of Colleges of Nursing, 2012, pp. 3-4). The nine Essentials addressed in this document delineate the knowledge and skills that all nurses prepared in master s nursing programs acquire: 1. Essential I: Background for Practice from Sciences and Humanities o Recognizes that the master s-prepared nurse integrates scientific findings from nursing, bio psychosocial fields, genetics, public health, quality improvement, and organizational sciences for the continual improvement of nursing care across diverse settings; 2. Essential II: Organizational and Systems Leadership o Recognizes that organizational and systems leadership are critical to the promotion of high quality and safe patient care. Leadership skills are needed that emphasize ethical and critical decision making, effective working relationships, and a systemsperspective; 3. Essential III: Quality Improvement and Safety o Recognizes that a master s-prepared nurse must be articulate in the methods, tools, performance measures, and standards related to quality, as well as prepared to apply quality principles within an organization; 4. Essential IV: Translating and Integrating Scholarship into Practice o Recognizes that the master s-prepared nurse applies research outcomes within the practice setting, resolves practice problems, works as a change agent, and disseminates results; 5. Essential V: Informatics and Healthcare Technologies o Recognizes that the master s-prepared nurse uses patient-care technologies to deliver and enhance care and uses communication technologies to integrate and coordinate care; 6. Essential VI: Health Policy and Advocacy o Recognizes that the master s-prepared nurse is able to intervene at the system level through the policy development process and to employ advocacy strategies to influence health and health care. 7. Essential VII: Inter-professional Collaboration for Improving Patient and Population Health Outcomes o Recognizes that the master s-prepared nurse, as a member and leader of inter- CoARC Report on Competency-Based Education 15

16 professional teams, communicates, collaborates, and consults with other health professionals to manage and coordinate care; 8. Essential VIII: Clinical Prevention and Population Health for Improving Health o Recognizes that the master s-prepared nurse applies and integrates broad, organizational, client-centered, and culturally appropriate concepts in the planning, delivery, management, and evaluation of evidence-based clinical prevention and population care and services to individuals, families, and aggregates/identified populations; 9. Essential IX: Master s-level Nursing Practice o Recognizes that nursing practice, at the master s level, is broadly defined as any form of nursing intervention that influences healthcare outcomes for individuals, populations, or systems. Master s-level nursing graduates must have an advanced level of understanding of nursing and relevant sciences as well as the ability to integrate this knowledge into practice. Nursing practice interventions include both direct and indirect care components (AACN, 2011, pp. 4-5). The Commission on Collegiate Nursing Education (CCNE), an accrediting agency that ensures the quality and integrity of baccalaureate, graduate, and residency programs in nursing publishes the Standards for Baccalaureate and Graduate Nursing Programs. While there are no defined competencies statements in this document, the CCNE requires programs to incorporate the Essentials document that corresponds to the degree program(s) that are offered by the institution. Specifically, Standard III B states that: Expected individual student learning outcomes are consistent with the roles for which the program is preparing its graduates. Curricula are developed, implemented, and revised to reflect relevant professional nursing standards and guidelines, which are clearly evident within the curriculum, expected individual student learning outcomes, and expected aggregate student outcomes (CCNE, 2009, p. 13). Another accrediting agency for the nursing profession, the National League for Nursing Accrediting Commission (NLNAC) publishes accreditation Standards and criteria for nursing programs at the practical, diploma, associate, baccalaureate, master s, and clinical doctorate levels. Standards refer to competencies established by the profession however no specific competencies are defined (NLNAC, 2008). Physician Assistant In an effort to define physician assistant competencies in response to similar efforts being conducted within other health care professions and growing demand for accountability and assessment in clinical practice, the physician assistant (PA) profession identifies core competencies for practicing PAs. The American Academy of Physician Assistants (AAPA), the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA), the National Commission on Certification of Physician Assistants (NCCPA), and the Physician Assistant Education Association (PAEA) disseminated the document CoARC Report on Competency-Based Education 16

17 Competencies for the Physician Assistant Profession in the spring of 2006 (AAPA, ARC-PA, NCCPA, & PAEA, 2005). Specifically, the PA competencies include the following six domains similar to the ACGME core competencies: 1. Medical knowledge o An understanding of pathophysiology, patient presentation, differential diagnosis, patient management, surgical principles, health promotion and disease prevention. Physician assistants must demonstrate core knowledge about established and evolving biomedical and clinical sciences and the application of this knowledge to patient care in their area of practice. In addition, physician assistants are expected to demonstrate an investigatory and analytic thinking approach to clinical situations; 2. Interpersonal and communication skills o Encompassing verbal, nonverbal and written exchange of information. Physician assistants must demonstrate interpersonal and communication skills that result in effective information exchange with patients, their patients families, physicians, professional associates, and the health care system; 3. Patient care o Includes age-appropriate assessment, evaluation and management. Physician assistants must demonstrate care that is effective, patient-centered, timely, efficient and equitable for the treatment of health problems and the promotion of wellness; 4. Professionalism o The expression of positive values and ideals as care is delivered. Foremost, it involves prioritizing the interests of those being served above one s own. Physician assistants must know their professional and personal limitations. Professionalism also requires that PAs practice without impairment from substance abuse, cognitive deficiency or mental illness. Physician assistants must demonstrate a high level of responsibility, ethical practice, sensitivity to a diverse patient population and adherence to legal and regulatory requirements; 5. Practice-based learning and improvement o Includes the processes through which clinicians engage in critical analysis of their own practice experience, medical literature and other information resources for the purpose of self-improvement. Physician assistants must be able to assess, evaluate and improve their patient care practices; 6. Systems-based practice o Encompasses the societal, organizational and economic environments in which health care is delivered. Physician assistants must demonstrate an awareness of and responsiveness to the larger system of health care to provide patient care that is of optimal value. PAs should work to improve the larger health care system of which their practices are a part. (AAPA, ARC-PA, NCCPA, & PAEA, 2005, pp. 1-5). CoARC Report on Competency-Based Education 17

18 The ARC-PA defines competencies as the knowledge, interpersonal, clinical and technical skills, professional behaviors, and clinical reasoning and problem solving abilities required for PA practice (ARC- PA, 2011, p. 24). The ARC-PA accreditation standards provide specific reference to competencies (but not specific reference to the competency document). For example, Standard B1.09 states that: For each didactic and clinical course, the program must define and publish instructional objectives that guide student acquisition of required competencies. ANNOTATION: Instructional objectives stated in measurable terms allow assessment of student progress in developing the competencies required for entry into practice. They address learning expectations of students and the level of student performance required for success (ARC- PA, 2011, p. 14). Further, Standard B3.02 refers to competencies in relation to the clinical portion of the curriculum: Supervised clinical practice experiences must enable students to meet program expectations and acquire the competencies needed for clinical PA practice (ARC-PA, 2011, p. 16). The ARC-PA also publishes a document comparing its accreditation standards to the competencies document (ARC-PA, 2010). While the purposes of the two documents are different and do not have word for word correlation, they are complimentary. Athletic Training The Professional Education Council (PEC) of the National Athletic Trainers Association (NATA) is responsible for developing the most recent edition of its professional competencies. Those involved in its development included practicing athletic trainers, educators, and administrators. Consideration was given to the existing healthcare environment as well as current best practices in athletic training. The AT competencies include all tasks identified in the role delineation study/practice analysis conducted by its credentialing board, the Board of Certification for the Athletic Trainer (BOC). The AT competency document identifies seven foundational behaviors of professional practice: (1) primacy of the patient, (2) team approach to practice, (3) legal practice, 4) ethical practice, (5) advancing knowledge, (6) cultural competence, (7) professionalism (NATA, 2011, p. 9). In addition, the document establishes eight competency domains as well as detailed competency statements for each domain. The eight domains are: (1) evidence-based practice; (2) prevention and health promotion; (3) clinical examination and diagnosis; (4) acute care of injuries and illnesses; (5) therapeutic interventions; CoARC Report on Competency-Based Education 18

19 (6) psychosocial strategies and referral; (7) healthcare administration; and (8) professional development and responsibility (NATA, 2011, pp ). The AT competencies serve as a companion document to the accreditation standards, which identify the requirements to acquire and maintain accreditation, published by the Commission on Accreditation of Athletic trainers (CAATE). The CAATE Standards provide specific reference to the NAATE competencies document. For example, Standard I3 states that: The content of the curriculum must include formal instruction in the expanded subject matter as identified in the Athletic Training Educational Competencies. Formal instruction must involve teaching of required subject matter with instructional emphasis in structured classroom and laboratory environments (CAATE, 2008, p. 9). Further, Standard J2 states that: Public Health Clinical experiences must provide students with opportunities to practice and integrate the cognitive learning, with the associated psychomotor skills requirements of the profession, to develop entry-level clinical proficiency and professional behavior as an Athletic Trainer as defined by the NATA Educational Competencies (CAATE, 2008, p. 10). The Council on Education for Public Health (CEPH) accreditation standards continues to require curriculum content and coursework based on five core areas of public health knowledge for programs offering the Masters of Public Health degree: (1) biostatistics, (2) epidemiology, (3) environmental health sciences, (4) health services administration, and (5) social and behavior sciences (Council on Education for Public Health, 2006). CEPH does not define a standardized list of competencies required for public health professionals graduating from accredited programs and institutions. Instead, the accreditation standards stress the importance of the required competencies related to the core knowledge areas for both guiding curriculum planning processes and serving as the primary measures against which student achievement is measured. For example, Standard 2.6 states that: For each degree program and area of specialization within each program identified in the instructional matrix, there shall be clearly stated competencies that guide the development of degree programs. The school must identify competencies for graduate professional public health, other professional and academic degree programs and specializations at all levels (bachelor s, master s and doctoral) (CEPH, 2011, p. 18). CoARC Report on Competency-Based Education 19

20 Pharmacy The Accreditation Council for Pharmacy Education (ACPE) defines three professional competencies, eleven other knowledge, skills, attitudes, and values, and two sub-competencies (Standard 12.1) in its accreditation standards for doctor of pharmacy degree programs. The three professional competencies specified in Standard 12 that must be achieved by graduates are: (1) Provide patient care in cooperation with patients, prescribers, and other members of an inter-professional health care team based upon sound therapeutic principles and evidence-based data, taking into account relevant legal, ethical, social, cultural, economic, and professional issues, emerging technologies, and evolving biomedical, pharmaceutical, social/behavioral/administrative, and clinical sciences that may impact therapeutic outcomes; (2) Manage and use resources of the health care system, in cooperation with patients, prescribers, other health care providers, and administrative and supportive personnel, to promote health; to provide, assess, and coordinate safe, accurate, and time-sensitive medication distribution; and to improve therapeutic outcomes of medication use; and (3) Promote health improvement, wellness, and disease prevention in cooperation with patients, communities, at-risk populations, and other members of an interprofessional team of health care providers. Standard 12 further states that: These professional competencies must be used to guide the development of stated student learning outcome expectations for the curriculum. To anticipate future professional competencies, outcome statements must incorporate the development of the skills necessary to become self-directed lifelong learners (ACPE, 2007, p. 18). Acupuncture and Oriental Medicine The Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM) is the national accrediting agency of first-professional master's degree and professional master's-level certificate and diploma programs in acupuncture and Oriental medicine, and professional post-graduate doctoral programs in acupuncture and in Oriental medicine (DAOM), as well as freestanding institutions and colleges of acupuncture and Oriental medicine that offer such programs. ACAOM Accreditation Criterion 7-2 describes the professional competencies required of graduates in three categories (1) patient care; (2) systems based medicine; and (3) professional development along with a number of domains and specific competency statements for each domain. For patient care, the eight competency domains are: (1) CoARC Report on Competency-Based Education 20

21 Foundational Knowledge, (2) Critical Thinking/Professional Judgment, (3) History Taking and Physical Examination, (4) Diagnosis, (5) Case Management, (6) AOM Treatment, (7) Emergency Care, and (8) Advanced Diagnostic Studies. For systems-based medicine, the three competency domains are: (1) Education and Communication, (2) Patient Care Systems, and (3) Collaborative Care. For professional development, the three competency domains are: (1) Ethics and Practice Management, (2) Formulating and Implementing Plans for Individual Professional Development, and (3) Incorporating Scholarship, Research and Evidence-Based Medicine/Evidence-Informed Practice into Patient Care (ACAOM, 2011, pp ). Dental Hygiene Standard 2-6 of the revised Dental Hygiene Standards published by the Commission on Dental Accreditation (CODA) requires its associate and baccalaureate degree programs to: Define and list the competencies needed for graduation. The dental hygiene program must employ student evaluation methods that measure all defined program competencies. These competencies and evaluation methods must be written and communicated to the enrolled students (CODA, 2013, p. 18). CODA also defines three general competency domains: (1) patient care, (2) ethics and professionalism, and (3) critical thinking. CODA further defines each of the competency domains as follows: Patient Care Competencies (Standard 2-16) (1) Graduates must be competent in providing dental hygiene care for the child, adolescent, adult and geriatric patient; (2) Graduates must be competent in assessing the treatment needs of patients with special needs; (3) Graduates must be competent in providing the dental hygiene process of care which includes (Standard 2-17): a) comprehensive collection of patient data to identify the physical and oral health status; b) analysis of assessment findings and use of critical thinking in order to address the patient s dental hygiene treatment needs; c) establishment of a dental hygiene care plan that reflects the realistic goals and treatment strategies to facilitate optimal oral health; d) provision of patient-centered treatment and evidence-based care in a manner minimizing risk and optimizing oral health; e) measurement of the extent to which goals identified in the dental hygiene care plan are achieved; f) complete and accurate recording of all documentation relevant to patient care; CoARC Report on Competency-Based Education 21